16 DEPARTMENT OF PUBLIC SAFETY

163 BUREAU OF EMERGENCY MEDICAL SERVICES (MAINE EMS)

CHAPTER 22: EMERGENCY MEDICAL SERVICES DATA

1. Definitions
2. “National data elements” means the specific EMS data elements defined by the national emergency medical services information system (NEMSIS).
3. “National emergency medical services information system (NEMSIS)” means the national EMS electronic database, as developed, and published by USDOT, NHTSA.
4. “Maine EMS patient care reporting System” means the Maine EMS electronic database, that meets the requirements of NEMSIS, provided by Maine EMS to all EMS agencies and EMS clinicians to record EMS incidents.
5. “Receiving Facility” means the hospital or any other facility the patient was transported to.
6. “Health Info Net (HIN)” means the independent, nonprofit information services organization that manages the statewide health information exchange (HIE) in Maine.
7. “Health Information Exchange (HIE)” is the statewide HIE designed to link an individual’s clinical information from unaffiliated healthcare sites to create a single electronic health record, allowing authorized providers across the state to better support and coordinate patient care.
8. Data Ownership
9. Data collected in the patient care reporting system is the property of the EMS submitting the data.
   1. Maine EMS shall have unrestricted access to the data within the patient care system.
   2. EMS agencies are responsible for the accuracy of the information entered into patient care and retain access to the data for the purpose of patient care. Moreover, EMS agencies may request data access logs for their data, which Maine EMS will provide within 14 days.
10. Patient Care Report Required
11. For each request for service, or for each patient when more than one patient is involved in a call, a service will require their EMS clinician primarily responsible for patient care to complete and submit an electronic Maine EMS patient care report, as specified by Maine EMS, within twenty-four hours from the incident completion date and time.
12. For each request for service, or for each patient when more than one patient is involved in a call, an EMS clinician who participated in the response must submit a completed electronic Maine EMS patient care report, as specified by Maine EMS, within twenty-four hours from the incident completion date and time.
13. Patient Care Report Requirements and Reporting Timeframe
14. Patient care reporting of EMS incidents by an EMS clinician or unit shall be made by providing the information in the Maine EMS Data Dictionary, as applicable, electronically, using software developed or purchased through contract, and distributed by Maine EMS.
15. When a patient is transported to a hospital/facility, the EMS clinician shall complete a patient care report and submit it within 24 hours of arriving at the destination facility and in accordance with the Maine EMS Protocols.
    1. A copy of the complete patient care report should be eft at the receiving facility whenever possible. In the event a complete patient care report cannot be left at the receiving facility prior to the departure of the ambulance crew, a Maine EMS approved hand-written short form must be left in all circumstances
16. Maine EMS shall provide non-mobile access to the electronic patient care reporting system at no cost to an EMS Agency.
17. Emergency Medical Services Monitoring of Health Outcomes
18. Maine Emergency Medical Services electronically transmits EMS patient care reports to Maine Health Info Net (HIN) for storage in the State of Maine Health Information Exchange (HIE).
    1. The following data elements will be requested from hospitals or physicians on all patients receiving emergency medical treatment as defined in Chapter 2 of these rules:
       1. Emergency Department Disposition
       2. Hospital Disposition
       3. External Report ID/Number Type
       4. External Report ID/Number
       5. Other Report Registry Type
       6. Emergency Department Chief Complaint
       7. First ED Systolic Blood Pressure
       8. Emergency Department Recorded Cause of Injury
       9. Emergency Department Procedures
       10. Emergency Department Diagnosis
       11. Date/Time of Hospital Admission
       12. Hospital Procedures
       13. Hospital Diagnosis
       14. Total ICU Length of Stay
       15. Total Ventilator Days
       16. Date/Time of Hospital Discharge
       17. Outcome at Hospital Discharge (e.g., Cerebral Performance Category Score or Scale at Hospital Discharge)
    2. records identifying a patient, in any format, that include HIV or AIDS status or test results, or that relate to referral, treatment or services for a behavioral or mental health disorder or substance use disorder are excluded from this requested data.
19. Hospitals and Physicians providing data to the state-designated statewide health information exchange as described in Title 22, section 1711-C, may notify the board of their decision to do so by submitting an authorization letter to each provider (i.e., hospital, physician) participating in the Health Information Exchange (HIE) with language to the effect of: “[Provider Entity Name] is a participant in the state-designated statewide Health Information Exchange as described in Title 22 MRSA §1711-C. By signing below, [Provider Entity Name] hereby authorizes the Board to receive [Provider Entity Name’s] healthcare information or records in accordance with Title 32 MRSA §96 (2)(A).”
    1. Providers may choose to not authorize the Board to retrieve their data from the HIE, those Hospitals and Physicians, must then provide the data directly to the Board
20. Hospitals and Physicians providing data to the state-designated statewide health information exchange as described in Title 22, section 1711-C may revoke that authorization by submitting a letter to the state-designated statewide health information exchange as described in Title 22, section 1711-C, revoking the Hospitals and Physicians previous authorization.
21. Maine EMS Posts all data requests received on the Maine EMS Website:
    1. The information shared will include the following:
       1. Date of request
       2. Date request was fulfilled
       3. The data elements that were requested
       4. The data elements that were provided
       5. The requestor
       6. The purpose of the request
       7. A copy of any agreement regarding the data release, if applicable
       8. Board of EMS authorization information, if applicable
22. Quality Assurance & Improvement
23. Quality initiatives are adopted in the following process:
    1. The Maine EMS Quality Assurance & Improvement Committee promulgates statewide quality initiatives for review and adoption by the Maine EMS Board,
24. Notification to providers regarding quality initiatives:
    1. Maine EMS shall provide a public list of Maine EMS Board approved quality initiatives on the website.

STATUTORY AUTHORITY: 32 M.R.S. § 96

EFFECTIVE DATE: December 24, 2022 – filing 2022-247